Female Testosterone Injection Intake, Consent & Provider Note

Female Testosterone Injection Intake, Consent & Provider Note

Complete this form to provide your medical history, consent, and understand the treatment process.
Patient Intake
Full Legal Name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider Name
Current Medications (list all prescription and non-prescription medications)
Allergy Information
List each allergy separately if you have more than one.
No known drug allergies?
If you have any allergies to medications/vitamins, please list them here:
Allergy severity
Allergy details
Currently pregnant?
Currently breastfeeding?
Last menstrual period (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last women’s health screening

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
History of hysterectomy?
History of oophorectomy?
Menopause or perimenopause?
Current estrogen therapy?
Current progesterone therapy?
History of breast cancer?
History of uterine/endometrial cancer?
History of ovarian cancer?
Unexplained vaginal bleeding?
PCOS?
Acne or hirsutism?
Hair thinning?
Voice changes?
Liver disease?
Cardiovascular disease?
History of clotting issue or blood clot?
Trying to conceive?
Have you used testosterone before?
Have you used anabolic steroids before?
Check any symptoms you are currently experiencing:

Other
Check any medical conditions you have (past or present):

Other
Safety Questions
Safety Questions (check any symptoms you are currently experiencing):
If you are experiencing any urgent symptoms, seek emergency care immediately. Do not wait for this visit.
Patient Acknowledgments / Consent
I certify that the information I provided is true, accurate, and complete to the best of my knowledge.
Patient Acknowledgments and Consents (check all to proceed):
Patient Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provider Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Provider Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Female Testosterone Injection Intake, Consent & Provider Note

Patient Intake

Allergy Information

Safety Questions

Patient Acknowledgments / Consent